Epidemiological and laboratory characteristics of multidrug-resistant tuberculosis patients in Bhutan, 2015-2019.

Background: Bhutan is no exception to the rising global threat of drug resistance tuberculosis (TB), particularly multidrug-resistant (MDR) TB. Although drug resistance surveillance has been carried out in Bhutan since 2010, limited analysis reports are available. Therefore, we looked at data from 2015-2019 to understand patient characteristics. Method: To obtain data for MDR-TB from the past 5 years, we looked at manual registers and laboratory worksheets for all samples received at National TB Reference Laboratory. Epidemiological factors and laboratory variables were analyzed using descriptive statistics. Result: Among 304 patients with MDR-TB, 85.20% (n=259) are new cases with no previous history of treatment. Those aged 16-25 years from both genders are affected more (46.05%, n=140) than other age groups. The majority (94.62%, n=264) of rifampicin resistance was found in the MUT 3 rpoB gene. For Isoniazid, 97.13% (n=271) resistance was seen in the MUT1 band of the katG gene. Conclusion: A high number of MDR-TB cases among new patients and little variation in the resistance band pattern over 5 years could indicate uncontrolled ongoing transmission. Whole-genome sequencing for the samples is required to further understand the epidemiology of the resistance pattern.

On-site domestic wastewater treatment system using shredded waste plastic bottles as biofilter media: Pilot-scale study on effluent standards in Bhutan.

In this study, a 1000 L/d capacity one-off on-site wastewater treatment system was operated for over a year as a pilot alternative to the conventional on-site treatment as currently used in urban Bhutan. An up-flow anaerobic sludge blanket (UASB) was used for blackwater treatment (to replace "septic tank followed by an anaerobic biofilter (ABF) (to replace soak pits) for the treatment of a mixture of greywater and UASB effluent. Shredded waste plastic bottles were used as the novel biofilter media in the ABF. During a yearlong operation, the pilot system produced a final treated effluent from ABF with average BOD5 28 mg/L, COD 38 mg/L, TSS 85 mg/L and 5 log units of Escherichia coli. These effluents met three out of four of the national effluent discharge limits of Bhutan, but unsuccessful to meet the Escherichia coli standard over a yearlong operation. Further, process optimisation may enable more significant Escherichia coli removal. An economic analysis indicates that the total unit cost (capital and operating expenditures) of this alternative wastewater treatment system for more than 50 users range between USD 0.27-0.37/person/month comparable to USD 0.29-0.42/person/month for the current predominant on-site system, i.e., "septic tanks". This pilot study, therefore, indicates that this wastewater treatment system using shredded waste plastic biofilter media has high potential to replace the current conventional treatment, i.e., "septic tanks", which are often overloaded with greywater and discharging effluents which does not meet the national standards.

Impact of source-separation of urine on treatment capacity, process design, and capital expenditure of a decentralised wastewater treatment plant.

In this study, the impact of urine diversion on the treatment capacity, treatment process, and capital costs of a decentralised wastewater treatment plant (WWTP) was simulated using BioWin. The data for simulation including for economic analysis were obtained from a real decentralised WWTP at Sydney. Simulation was conducted for two alternative process design scenarios of a WWTP: membrane bioreactor (MBR) without denitrification and anaerobic MBR in place of aerobic MBR and compared to existing process design. The simulation shows that with about 75% urine diversion (through source separation), the treatment capacity of the existing WWTP can be doubled although above 40% urine diversion, the impact appears less rapid. When the urine diversion exceeds 75%, it was found that the anoxic tank for biological denitrification becomes redundant and the current wastewater treatment process could be replaced with a simpler and much less aeration intensive membrane bioreactor (MBR) producing similar effluent quality with a 24% reduction in capital expenditure (footprint) cost. Anaerobic MBR can be a potential alternative to aerobic MBR although pre-treatment becomes essential before reverse osmosis treatment for water reuse applications. Sensitivity analysis has revealed that by operating the bioreactor at higher mixed liquor suspended solids concentrations (9 g/L instead of 5 g/L) could help increase the WWTP treatment capacity by about 3.5 times at 75% urine diversion. Hence, urine diversion (until nitrogen-limiting conditions occur above 75% urine diversion) can increase the treatment capacity of an existing WWTP and reduce the capital expenses due to reduced plant footprint.

Removal of pharmaceuticals from nitrified urine.

In this study, granular activated carbon (GAC) was examined for the removal of five of the most commonly detected pharmaceuticals (naproxen, carbamazepine, acetaminophen, ibuprofen and metronidazole) from a nitrified urine to make the urine-derived fertiliser nutrient safe for food crops. Batch experiments were conducted to investigate the adsorption kinetics that described the removal of micropollutants (equal concentrations of 0.2 mM) from the synthetic nitrified urine at different GAC dosages (10-3000 mg/L). Artificial neural network modelling was also used to predict and simulate the removal of pharmaceuticals from nitrified urine. Langmuir and Freundlich isotherm models described the equilibrium data, with the Langmuir model providing slightly higher correlations. At the highest dose of 3000 mg/L GAC, all the pharmaceuticals showed a removal rates of over 90% after 1 h of adsorption time and 99% removal rates after 6 h of adsorption time. This study concludes that GAC is able to remove the targeted xenobiotics without affecting the concentration of N and P in the urine, suggesting that nitrified urine could be safely used as a nutrient product in future.